LEARNING OBJECTIVE
After this activity, the participant will be able to identify relevant diagnostic and therapeutic modalities when approaching patients with extrahepatic and perihilar strictures.
QUESTION 1
A 69-year-old woman is referred to your clinic for abdominal discomfort, jaundice, and itching. On examination, she appears jaundiced and has mild upper abdominal tenderness. Liver tests are notable for aspartate transaminase (AST) 347 U/L (normal: 0–35 U/L), alanine transaminase (ALT) 440 U/L (normal: 0–35 U/L), alkaline phosphatase (ALP) 628 U/L (normal: 0–35 U/L), total bilirubin 7.2 mg/dL (normal: 0–1.2 mg/dL). You obtain abdominal computed tomography (CT) scan which shows moderate intrahepatic and proximal extrahepatic biliary ductal dilatation upstream of an ill-defined pancreatic head mass.
Which of the following is the recommended next step in this patient's management?
- Endoscopic retrograde cholangiopancreatography (ERCP) with placement of an uncovered metal biliary stent
- ERCP with brush cytology and forceps biopsies of the biliary stricture
- Endoscopic ultrasound (EUS) with fine-needle sampling of the pancreatic mass
- Percutaneous transhepatic biliary drainage (PTBD)
QUESTION 2
A 45-year-old man with a past medical history of gastroesophageal reflux disease, alcohol use, and chronic pancreatitis presents to the emergency department with a 3-week history of increasing right upper quadrant pain and jaundice. The patient reports no fever or weight loss. Laboratory test results were normal except for AST 181 U/L (normal: 0–35 U/L), ALT 247 U/L (normal: 0–35 U/L), ALP 463 U/L (normal: 0–35 U/L), total bilirubin 5.8 mg/dL (normal: 0–1.2 mg/dL). Subsequently, he underwent a CT of the abdomen and pelvis which showed a smooth, relatively-short distal common bile duct stricture with upstream biliary dilation with pancreatic head calcifications and atrophy.
What is the preferred endoscopic modality for durable treatment of this patient's biliary stricture?
- Placement of a fully covered metal stent for 6 months
- Placement of a single plastic stent for 6 months
- Sequential placement of multiple plastic stents for 3–6 months
- Placement of an uncovered metal stent for 6 months
QUESTION 3
What is the next recommended diagnostic step for a patient with a suspected malignant perihilar stricture due to cholangiocarcinoma?
- EUS-based sampling of the primary lesion
- Percutaneous biopsy of the primary lesion
- Brush cytology at the time of index ERCP
- Multimodality sampling at the time of index ERCP
